Medicine thrives on dissent. Of all the medical disciplines, psychiatry
seems to generate the highest level of dissent, both from inside and outside
the profession: no other medical discipline, for example, has some of its own
members consistently argue that its very foundations are rooted in a series of
harmful myths (Szasz, 1974,
2003). The best responses to
this type of criticism identify the core concerns of the critic, dissect out
the most relevant arguments and develop ways to integrate useful suggestions
with existing knowledge, so as to advance the field in a pragmatic, sensible
and evidence-based fashion. Such constructive responses to controversy are
rare.

Thirty years ago, Dr Anthony Clare produced what was arguably the most
comprehensive and constructive commentary on controversial issues in
psychiatry to be published in a generation, in his now-classic book,
Psychiatry in Dissent: Controversial Issues in Thought and Practice
(Clare, 1976). At that time, Dr
Clare was a research worker at the Institute of Psychiatry and honorary senior
registrar at the Bethlem and Maudsley Hospitals, London.

Psychiatry in Dissent was a highly ambitious book, aimed at
providing a rational counter-argument to the most trenchant critics of
psychiatry in the 1970s, and establishing a reasoned middle ground between the
anti-psychiatry movement and the emergent school of biological psychiatry.
Psychiatry in Dissent proved to have an enormous impact: not only did
it provide a reasoned response to critics of psychiatry in the 1970s but it
also provided intellectual inspiration to a generation of psychiatric trainees
(e.g. Wessely, 2002). It
remains in print today, as part of Routledge’s ‘International
Behavioural and Social Sciences Library: Classics from the Tavistock
Press’ (Clare, 2001). The
purpose of this paper is to provide a brief overview of the contemporary
relevance of Psychiatry in Dissent on the 30th anniversary of its
publication.

The myth of the myth of mental illness

Clare started his book by focusing on the very concept of mental illness
and addressing the criticisms of psychiatric diagnosis and classification
presented by, among others, Szasz, Laing and Foucault. Clare acknowledged the
problems presented by psychiatric classification and explored several
diagnostic dilemmas that illustrated the limitations of existing systems,
including the case of a 16-year-old boy who was described as aggressive,
disruptive and remorseless, but did not show signs of affective or psychotic
disturbance. Clare noted that in this case most psychiatrists would consider a
diagnosis of personality disorder, but ‘where disagreement would appear
would be over the question of whether such a person is actually ill.
Disturbed he may be, unhappy even, but is he ill? ’
(Clare, 1976, p. 20). Today,
the values of specific systems of psychiatric classification continue to be
debated within the profession. Indeed, these issues may well have become more
acute in recent years, following the emergence of novel diagnostic categories
such as ‘severe dangerous personality disorder’ whose societal and
legal convenience may appear substantially to exceed their clinical provenance
(White, 2002).

Clare’s explicit defence of psychiatric classification throughout
Psychiatry in Dissent is a reflection of the turbulent times in which
the book first appeared, when psychiatry was facing radical criticism in
relation to such fundamental issues as the validity of the concept of mental
illness and the usefulness of psychiatric classification. These debates, once
a dominant feature of psychiatric discourse, have over the past 30 years
become more measured but at the same time more peripheral. This is
attributable to a number of factors including the development of more
fine-grained atheoretical classification systems that are designed as
diagnostic tools rather than absolute systems, and the acknowledgement that
many advances in psychiatric research have depended upon the delineation and
study of discrete syndromic entities, which have helped to optimise the
reliability and comparability of research findings across different
centres.

Another defence offered by Clare was that, contrary to the claims of the
anti-psychiatry movement, clinically based classification systems actually
help to protect the individual from being labelled mentally ill for
purposes of societal or political convenience. As Clare wrote, ‘What
protects the dissident, the deviant, and the outsider from being labeled “
mentally ill” is not the psychiatrist who does not believe in
psychiatric classifications... but rather the psychiatrist who acknowledges
that people can suffer from serious mental disturbances, that the symptoms of
these can be grouped and defined in such a way as to produce a reasonable
degree of agreement as to their validity and reliability, and that those
people who do not show such symptoms cannot be classified as mentally ill,
whatever society may say or do’
(Clare, 1976, p. 156). In the
30 years since Psychiatry in Dissent first appeared, the importance
of Clare’s defence of clinical classification has been demonstrated
again and again, particularly in the context of the alleged labelling of
political dissidents as mentally ill in the former Soviet Union in the 1970s
and 1980s (Bloch & Reddaway,
1984) and more recently in the People’s Republic of China
(Munro, 2000).

Dichotomies, discussions and other unfinished business

Although generally defending the usefulness of the concept of disease
entities, Clare warned ‘it is probably a mistake to conceptualise
normality and madness as dichotomous, that is to say as states of mind,
inhabitation of one necessarily mitigating against the other. Rather they are
best thought of as opposite ends of a continuum, a continuum on which most of
us find ourselves positioned in that grey and shady area between the two
opposing poles’ (Clare,
1976, p. 32). When these words were written, the idea of a
continuum of illness had a long history in relation to affective disorders,
but the subsequent 30 years have produced considerable evidence of another,
less obvious, continuum in relation to the psychoses, based on increasing
evidence of psychotic and quasi-psychotic phenomena in the general population
who do not meet the formal criteria for psychotic illness
(Verdoux & Van Os,
2002).

Focusing further on the ways in which clinicians conceptualise
psychological disorders, Clare went on to emphasise ‘it is no longer
possible to identify a state, reaction or disease as physical or
psychological. An emotion, such as phobic anxiety... can be described in
psychological terms as a “fear” or a “terror” or in
the physiological language of autonomic nervous system function and hormonal
secretion. Forced by the considerations of pragmatism and convenience to opt
for one or other of the two languages, somatic and psychological, with which
to describe psychiatric phenomena, psychiatrists create the unfortunate
impression that there are two distinct kinds of disease-organic and
functional’ (Clare, 1976,
p. 33). This misleading distinction between ‘psychological’ and ‘
physical’ phenomena remains as unhelpful today as it was in 1976,
and it still supports a false dichotomy between mind and brain that continues
to distort perceptions of mental illness
(Andreason, 2001).

Clare does not shy away from contrary arguments or awkward positions, and
does not hesitate to acknowledge the relative merits of conflicting approaches
to different issues. Today, there may be less fundamental dissent about issues
such as the validity of the concept of mental illness or the overall
usefulness of psychiatric classification, but there remains an active critical
psychiatry movement whose ideas continue to challenge and illuminate
difficulties in these areas (for a recent review see
Thomas & Bracken, 2004).
Moreover, there is increased concern about different, more specific issues,
such as the effects of the pharmaceutical industry on psychiatric practice
(Healy & Cattell, 2003), or
the merits of particular diagnostic categories
(Hsieh & Kirk, 2003).
Clearly, the reasoned, logical and balanced approach to conflict, as
demonstrated in Psychiatry in Dissent, is still as necessary and
relevant as ever.

Interestingly, even though some of the themes of conflict have changed over
the past 30 years, many of the topics explored in Psychiatry in
Dissent remain very relevant today, albeit in different ways. For
example, Clare’s discussion of psychosurgery in children as young as 5
years now serves as a strong defence of contemporary models of evidence-based
medicine, even though Clare was writing some 20 years before the recurrent
concept of evidence-based medicine enjoyed its most recent renaissance
(Sackett et al, 1996).
Clare’s comments on schizophrenia serve as a poignant reminder of how
little has changed, as it broadly remains the case that ‘for all the
advances, in understanding and in treatment, the condition remains a baffling
and enigmatic one, a harrowing experience for the individual sufferer, and a
challenge to the ingenuity and skill of those intent on unlocking its
secrets’ (Clare, 1976,
pp. 214–215).

In an era when much psychiatric debate is characterised by a ‘sea of
rhetorical vituperation’ (Clare,
1976, p. 306), and psychiatric training is increasingly based on
vapid multi-author texts, Psychiatry in Dissent serves as an
affirmation of the ability of the thoughtful individual psychiatrist to make
sense of the controversies that rage within psychiatry. It is also a testament
to the importance of applying recent advances in thought and practice to the
development of models of patient care that are equitable, acceptable,
evidence-based and, most of all, effective.

Acknowledgments

Quotations from Psychiatry in Dissent: Controversial Issues in Thought
and Practice (Clare, 1976)
are reproduced by kind permission of Routledge and with the agreement of
Professor Anthony Clare.